WORLD DRUG REPORT. Research

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1 216 Research WORLD DRUG REPORT

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3 UNITED NATIONS OFFICE ON DRUGS AND CRIME Vienna World Drug Report 216 UNITED NATIONS New York, 216

4 United Nations, May 216. All rights reserved worldwide. ISBN: eisbn: United Nations publication, Sales No. E.16.XI.7 This publication may be reproduced in whole or in part and in any form for educational or non-profit purposes without special permission from the copyright holder, provided acknowledgement of the source is made. The United Nations Office on Drugs and Crime (UNODC) would appreciate receiving a copy of any publication that uses this publication as a source. Suggested citation: United Nations Office on Drugs and Crime, World Drug Report 216 (United Nations publication, Sales No. E.16.XI.7). No use of this publication may be made for resale or any other commercial purpose whatsoever without prior permission in writing from UNODC. Applications for such permission, with a statement of purpose and intent of the reproduction, should be addressed to the Research and Trend Analysis Branch of UNODC. DISCLAIMER The content of this publication does not necessarily reflect the views or policies of UNODC or contributory organizations, nor does it imply any endorsement. Comments on the report are welcome and can be sent to: Division for Policy Analysis and Public Affairs United Nations Office on Drugs and Crime PO Box 5 14 Vienna Austria Tel: (+43) Fax: (+43) wdr@unodc.org Website:

5 WORLD DRUG REPORT iii PREFACE The World Drug Report 216 comes at a decisive moment, just months after Member States, at a special session of the General Assembly, adopted a comprehensive set of operational recommendations on the world drug problem. The session was only the third in the history of the General Assembly to focus on drugs, and the resulting outcome document, entitled Our joint commitment to effectively addressing and countering the world drug problem, provides a concrete way forward to take action on shared challenges. In the outcome document, Member States reaffirmed their commitment to addressing persistent, new and evolving challenges in line with the three international drug control conventions, which were recognized as allowing States parties sufficient flexibility to design and implement national drug policies consistent with the principle of common and shared responsibility. The operational recommendations contained in the outcome document encompass measures to address demand and supply reduction, as well as to improve access to controlled medicines while preventing their diversion; they cover human rights, youth, children, women and communities and highlight emerging challenges and the need to promote long-term, comprehensive, sustainable, development-oriented and balanced drug control policies and programmes that include alternative development. The text highlights the importance of drug abuse prevention and treatment; encourages the development, adoption and implementation of alternative or additional measures with regard to conviction or punishment; and promotes proportionate national sentencing policies, practices and guidelines for drug-related offences. Now the international community must come together to make good on its commitments. The World Drug Report 216, which provides a comprehensive overview of major developments in drug markets, trafficking routes and the health impact of drug use, supports comprehensive, balanced and integrated rights-based approaches. This year s report offers insight into the wide-ranging impact of drugs not only on the health and well-being of individuals, but also on the people around them families and communities. This can include such harms as HIV, as well as the threat of violence, faced in particular by women and children. The report also flags the alarming rise in heroin use in some regions. While the challenges posed by new psychoactive substances remain a serious concern, heroin continues to be the drug that kills the most people. This resurgence must be addressed urgently. The report looks at issues of gender, marginalization, stigmatization, violence and human rights, and considers how counter-narcotics strategies can be sensitive to environmental concerns such as deforestation and pollution. It examines the use of the dark net and new technologies for drug trafficking, as well as the potential of illicit drug profits to fund terrorism and violent extremism. Moreover, the 216 report s thematic chapter focuses on the interlinkages between drugs and development and the importance of development-sensitive drug control policies. This is a topic of particular relevance: as Governments noted in the outcome document, efforts to achieve the Sustainable Development Goals and to effectively address the world drug problem are complementary and mutually reinforcing. The research contained in the report can support effective drug and development policies. The evidence is clear: illicit drug cultivation and manufacturing can be eradicated only if policies are aimed at the overall social, economic and environmental development of communities; confronting drug trafficking and its associated violence requires strong, transparent and fair criminal justice institutions and targeted efforts to dismantle transnational organized criminal organizations; prevention and treatment of drug use work if they are based on scientific evidence and are gendersensitive; and the excessive use of imprisonment for drugrelated offences of a minor nature is ineffective in reducing recidivism and overburdens criminal justice systems. There is clearly much work to be done to tackle the many evolving and emerging challenges posed by drugs. The outcome document and its operational recommendations offer a solid foundation, one built on agreed frameworks, informed by evidence and based on the principle of common and shared responsibility. This report, as with all of the Office s expertise and on-theground experience in addressing the many aspects of the world drug problem, is at the disposal of Member States as they strive to meet this call to action. Yury Fedotov Executive Director United Nations Office on Drugs and Crime WORLD DRUG REPORT 216

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7 WORLD DRUG REPORT v CONTENTS PREFACE EXPLANATORY NOTES EXECUTIVE SUMMARY CONCLUSIONS iii vii ix xxiii 1. ILLICIT DRUG MARKETS: SITUATION AND TRENDS A. Extent of drug use 1 B. Health impact of drug use 14 C. Extent of drug supply 21 D. Market analysis by drug type 26 Opiates 26 Cocaine 35 Cannabis 43 Synthetic drugs: amphetamine-type stimulants and new psychoactive substances THE WORLD DRUG PROBLEM AND SUSTAINABLE DEVELOPMENT A. Social development 64 B. Economic development 75 C. Environmental sustainability 86 D. Peaceful, just and inclusive societies 95 E. Partnership 15 ANNEX Statistical tables Regional groupings Glossary i xxxv xxxvii WORLD DRUG REPORT 216

8 Acknowledgements The World Drug Report 216 was prepared by the Research and Trend Analysis Branch, Division for Policy Analysis and Public Affairs, United Nations Office on Drugs and Crime, under the supervision of Jean-Luc Lemahieu, Director of the Division, and Angela Me, Chief of the Research and Trend Analysis Branch. Core team Research, study preparation and drafting Coen Bussink David Macdonald Chloé Carpentier Kamran Niaz Liliana M. Dávalos Thomas Pietschmann Philip Davis Martin Raithelhuber Angelica Durán-Martínez Clinton W. Saloga Natascha Eichinger Justice Tettey Jon Flanders Freya Vander Laenen Anja Korenblik Antoine Vella Sabrina Levissianos Graphic design and layout Suzanne Kunnen Kristina Kuttnig Data processing and mapping support Gerald Kandulu Preethi Perera Umidjon Rakhmonberdiev Ali Saadeddin Editing Jonathan Gibbons Coordination Francesca Massanello Review and comments The present report also benefited from the expertise and valuable contributions of UNODC colleagues in the Corruption and Economic Crime Branch and the Organized Crime and Illicit Trafficking Branch of the Division for Treaty Affairs; and the Drug Prevention and Health Branch, the Prevention, Treatment and Rehabilitation Section, the HIV/AIDS Section and the Justice Section of the Division for Operations. The Research and Trend Analysis Branch acknowledges the invaluable contributions and advice provided by the World Drug Report Scientific Advisory Committee, which was formed in 215 with the following members: Jonathan Caulkins Paul Griffiths Marya Hynes Vicknasingam B. Kasinather Letizia Paoli Charles Parry Peter Reuter Francisco Thoumi Alison Ritter Brice De Ruyver The Research and Trend Analysis Branch is also grateful for the waste-water analysis data provided by SEWPROF and the Sewage Analysis CORe group Europe (SCORE), which was used in chapter I of the present report. The HIV research for chapter I of the present report was funded in part by the Drug Prevention and Health Branch and the HIV/AIDS Section of the Division for Operations of UNODC. The research for chapter II was made possible by the generous contribution of the Russian Federation and the German Agency for International Cooperation (GIZ).

9 WORLD DRUG REPORT vii EXPLANATORY NOTES The boundaries and names shown and the designations used on maps do not imply official endorsement or acceptance by the United Nations. A dotted line represents approximately the line of control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. Disputed boundaries (China/India) are represented by cross-hatch owing to the difficulty of showing sufficient detail. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal status of any country, territory, city or area, or of its authorities or concerning the delimitation of its frontiers or boundaries. Countries and areas are referred to by the names that were in official use at the time the relevant data were collected. All references to Kosovo in the present publication should be understood to be in compliance with Security Council resolution 1244 (1999). Since there is some scientific and legal ambiguity about the distinctions between drug use, drug misuse and drug abuse, the neutral terms drug use and drug consumption are used in the present report. All uses of the word drug in this report refer to substances under the control of the international drug control conventions. All analysis contained in this report is based on the official data submitted by Member States to the United Nations Office on Drugs and Crime through the annual report questionnaire unless indicated otherwise. The data on population used in the present report are from: United Nations, Department of Economic and Social Affairs, Population Division, World Population Prospects: The 215 Revision. References to dollars ($) are to United States dollars, unless otherwise stated. References to tons are to metric tons, unless otherwise stated. R stands for the correlation coefficient, used as measure of the strength of a statistical relationship between two or more variables, ranging from to 1 in case of a positive correlation or from to -1 in case of a negative correlation; R2 stands for the square of the coefficient of correlation. The following abbreviations have been used in the present report: ATS CICAD CND EMCDDA Europol GDP ha INCB INCSR INTERPOL MDMA MSM MDPV NIDA NPS OECD amphetamine-type stimulants Inter-American Drug Abuse Control Commission (Organization of American States) Commission on Narcotic Drugs European Monitoring Centre for Drugs and Drug Addiction European Police Office gross domestic product hectares International Narcotics Control Board International Narcotics Control Strategy Report of the United States State Department International Criminal Police Organization 3,4-methylenedioxymethamphetamine Men who have sex with men 3,4-methylenedioxypyrovalerone National Institute on Drug Abuse (United States) new psychoactive substances Organization for Economic Cooperation and Development WORLD DRUG REPORT 216

10 viii PMMA PWID alpha-pvp SAMHSA SCORE UNAIDS UNDP UNFDAC WCO WHO para-methoxymethamphetamine people who inject drugs alpha-pyrrolidinopentiophenone Substance Abuse and Mental Health Services Administration (United States of America) Sewage Analysis CORe group Europe Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Fund for Drug Abuse Control World Customs Organization World Health Organization

11 WORLD DRUG REPORT ix EXECUTIVE SUMMARY We reiterate our commitment to strengthen our efforts in addressing and countering emerging and persistent challenges and threats of all aspects of the world drug problem and we recommend the following: promote, as appropriate, the use and analysis of relevant, reliable and objective data to improve the implementation of comprehensive, integrated and balanced national drug control strategies, policies and programmes and encourage the sharing of best practices and lessons learned. Outcome document of the special session of the General Assembly on the world drug problem, entitled Our joint commitment to effectively addressing and countering the world drug problem The World Drug Report 216 is published in the wake of the landmark moment in global drug policy, the special session of the General Assembly on the world drug problem. Chapter I provides a global overview of the supply of and demand for opiates, cocaine, cannabis, amphetamine-type stimulants (ATS) and new psychoactive substances (NPS), as well as their impact on health. It also reviews the scientific evidence on polydrug use, treatment demand for cannabis and developments since the legalization of cannabis for recreational use in some parts of the world. Chapter II focuses on the mechanisms of the interaction between the world drug problem and all aspects of sustainable development through the lens of the Sustainable Development Goals. Drug use and its health consequences It is estimated that 1 in 2 adults, or a quarter of a billion people between the ages of 15 and 64 years, used at least one drug in 214. Roughly the equivalent of the combined populations of France, Germany, Italy and the United Kingdom, though a substantial amount, it is one that does not seem to have grown over the past four years in proportion to the global population. Nevertheless, as over 29 million people who use drugs are estimated to suffer from drug use disorders, and of those, 12 million are people who inject drugs (PWID), of whom 14. per cent are living with HIV, the impact of drug use in terms of its consequences on health continues to be devastating. With an estimated 27,4 drug-related deaths in 214, corresponding to 43.5 deaths per million people aged 15-64, the number of drug-related deaths worldwide has also remained stable, although unacceptable and preventable. Overdose deaths contribute to between roughly a third and a half of all drug-related deaths, which are attributable in most cases to opioids. The time period shortly after release from prison is associated with a substantially Prevalence of injecting drug use, 214 or latest available year Ç Ç Ç Ç Ç ÇÇ Ç ÇÇ Ç Ç ÇÇ Percentage of population aged > 1. No data provided Note: The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. The final boundary between the Sudan and South Sudan has not yet been determined. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). WORLD DRUG REPORT 216

12 x 247 million people used drugs in the past year 29 million suffer from drug use disorders but only 1 in 6 people with drug use disorders is in treatment increased risk of death from drug-related causes (primarily as a result of drug overdoses), with a mortality rate much higher than from all causes among the general population. In many countries, prisons remain a high-risk environment for infectious diseases, which is a significant concern for prison health. A number of studies report high levels of drug use in prison, including the use of opiates and injecting drug use. In addition, the prevalence of HIV, hepatitis and tuberculosis among persons held in prison can be substantially higher than among the general population. However, despite the high-risk environment and scientific evidence for effective health interventions, there are significant gaps in prevention and treatment services in many prisons around the world. PWID experience some of the most severe health-related harms associated with unsafe drug use, overall poor health outcomes, including a high risk of non-fatal and fatal overdoses, and a greater chance of premature death. One in seven PWID is living with HIV, and one in two with hepatitis C. PWID are a key at-risk population for HIV and hepatitis, with almost a third of new HIV infections outside sub-saharan Africa occurring among PWID. Moreover, studies have found people who inject stimulants to engage in more risky sexual behaviours, resulting in a higher risk of HIV infection than for those injecting opiates. Cannabis remains the most commonly used drug at the global level, with an estimated 183 million people having used the drug in 214, while amphetamines remain the second most commonly used drug. With an estimated 33 million users, the use of opiates and prescription opioids is less common, but opioids remain major drugs of potential harm and health consequences. The fact that a sharp increase in heroin use has been documented in some markets (particularly North America) where it was previously declining, shows that heroin remains one of the major drugs of public health concern. 12 million people inject drugs 1.6 million people who inject drugs are living with HIV 6 million are living with hepatitis C

13 EXECUTIVE SUMMARY xi Global trends in the estimated prevalence of drug use, Global trends in the estimated number of people who use drugs, Annual prevalence (percentage) % 4.9% 5.% 5.2% 5.2% 5.2% 5.2% 4.6% 4.8%.6% Annual drug users (millions) Prevalence of people who use drugs (percentage) Prevalence of people with drug use problems (percentage) Number of people who use drugs Number of people with drug use problems Source: Responses to the annual report questionnaire. Note: Estimated percentage of adults (ages 15-64) who used drugs in the past year. Source: Responses to the annual report questionnaire. Note: Estimates are for adults (ages 15-64), based on past-year use. As an overall trend at the global level, the use of cannabis has remained stable over the past three years. In some subregions, however, particularly North America and Western and Central Europe, cannabis use has increased. After a period of stability, since 21 cocaine use has also been rising, mainly because of an increase in cocaine use in South America. On the other hand, the use of amphetamines appears to be stable, but that may underplay the situation in subregions, specifically East and South-East Asia, where recent information on the extent of drug use is unavailable. Making the global picture of drug use more blurred is the fact that many people who use drugs, both occasionally and regularly, tend to be polydrug users who use more than one substance concurrently or sequentially. For example, the non-medical use of prescription drugs, synthetic stimulants and NPS in lieu of or in combination with more conventional drugs clouds the distinction between users of a particular drug, presenting an interlinked or cyclical epidemic of drug use and related health consequences in recent years. Treatment related to cannabis use has been increasing in many regions over the past decade. In Europe, an increase in the numbers in treatment for cannabis use has been observed in several countries, despite a decline in the number of frequent (monthly) users. The proportion of people seeking treatment for the first time for cannabis use disorders remains high globally, with nearly half of the people treated for cannabis use disorders being first-time entrants. Changes in patterns of the people in treatment for cannabis use may be attributed to a number of factors, including practices in referrals by the criminal justice system and an expansion in the provision of treatment for cannabis in some countries. While there is some evidence that higher potency cannabis is now more widely available in Europe and the United States, how this might translate into greater harm for cannabis users is not clearly understood. On average, younger people are seeking treatment for cannabis and amphetamines use disorders more than for other drugs. This reflects the trends in increasing use of cannabis and amphetamines and the resulting increase in people seeking treatment for disorders related to the use of cannabis and amphetamines. People in treatment for opioidor cocaine-related disorders are typically in their thirties, and, in many subregions, this reflects an ageing cohort of users in treatment and an overall decrease in the proportion of treatment demand. Overall, men are three times more likely than women to use cannabis, cocaine or amphetamines, whereas women are more likely than men to engage in the non-medical use of opioids and tranquilizers. Gender disparities in drug use are more attributable to opportunities to use drugs in a social environment than to either gender being more or less susceptible or vulnerable to the use of drugs. Moreover, while in most surveys the prevalence of drug use among young people is reportedly higher than among adults, the gender divide in drug use is narrower among young people than among adults. WORLD DRUG REPORT 216

14 xii DRUG SUPPLY AND MARKETS The most widely cultivated drug crop continues to be cannabis, which was reported by 129 countries over the period , far more than the 49 countries that reported opium poppy cultivation (mostly located in Asia and the Americas) and the 7 countries that reported coca cultivation (located in the Americas). Leaving aside the disparity in their respective numbers of cultivating countries, opium poppy cultivation has been decreasing in the past year while coca cultivation has been rising. Cannabis also continues to be the most trafficked drug worldwide, while there has been a large increase in seizures of synthetic drugs. Although there were 234 substances under international control in 214 (244 in January 216), the bulk of trafficking (based on reported drug seizures, which reflect both law enforcement activity and drug flows) was concentrated on a far smaller number of substances. Cannabis in its various forms was intercepted in 95 per cent of reporting countries in 214 and accounted for over half of the 2.2 million drug seizure cases reported to the United Nations Office on Drugs and Crime (UNODC) that year, followed by ATS, opioids and coca-related substances. In all countries, more men (9 per cent of the total, on average) than women are brought into formal contact with the criminal justice system for trafficking in drugs or for possession of drugs for personal use. However, the reporting of gender-disaggregated data has improved over the years and shows an increased number of women arrested for drug-related offences in absolute terms. Nevertheless, the proportion of women in drug-related arrests, while fluctuating, showed a downward trend over the period, particularly for drug trafficking-related offences. Index (base: 1 in 1998) Trends in the quantities of drugs seized worldwide, Source: Responses to the annual report questionnaire. 212 Cannabis herb and resin Cocaine hydrochloride, "crack" cocaine and cocaine base and paste Heroin and morphine Amphetamine-type stimulants (ATS) 214 Drug supply via the Internet, including via the anonymous online marketplace, the dark net, may have increased in recent years. This raises concerns in terms of the potential of the dark net to attract new populations of users by facilitating access to drugs in both developed and developing countries. Opiates Primarily carried out in South-West Asia and, to a lesser extent, in South-East Asia and Latin America, global opium production in 215 fell by 38 per cent from the previous year to some 4,77 tons, i.e., to the levels of the late 199s. The decrease was primarily a consequence of a decline in opium production in Afghanistan (a decrease of 48 per cent from the previous year), mainly as a result of poor yields in the country s southern provinces. However, at 183, hectares, Afghanistan still accounted for almost two thirds of the global area under illicit opium poppy cultivation, which decreased by 11 per cent from the previous year to around 281, hectares. UNODC estimates indicate that the global number of opiate users (i.e., users of opium, morphine and heroin) has changed little in recent years and that opiates continued to affect some 17 million people in 214. It seems unlikely that the sharp decline in opium production in 215 will lead to major shortages in the global heroin market given the high opium production levels of previous years. The build-up or depletion of previous years opium inventories may be used to offset annual changes in production and maintain the supply of heroin to user markets. It may take a period of sustained decline in opium production for the repercussions to be felt in the heroin market. Indeed, the global opiate market appears to be stable despite important regional changes. There are indications that heroin use may be undergoing a resurgence in some countries where it was previously declining. Heroin use increased in North America in the past decade, which resulted in an increase in the level of heroin-related deaths. Long-term trends, in contrast, have been stable or declining in Western and Central Europe since the late 199s. There are early signs, however, of a surge in the heroin market, with an increase in the availability and use of heroin in some markets in Europe, as well as a major increase in the size of individual seizure cases of heroin destined for Europe. Meanwhile, based on trend perceptions reported to UNODC, the use of opioids may have grown in Africa. Overall opiate use in Asia is reported by experts to have remained largely unchanged over the period , whereas opiate use in Oceania has declined. The global interception rate for opiates doubled from the period (particularly after the special session of the General Assembly on the world drug problem in 1998) to the period. The largest amount of opiates

15 EXECUTIVE SUMMARY xiii Main trafficking flows of heroin Russian Federation Pakistan Canada United States of America Mexico WEST AFRICA WESTERN, CENTRAL AND SOUTH EASTERN EUROPE Turkey Islamic Republic of Iran Persian Gulf area & Middle East CENTRAL ASIA Afghanistan Pakistan China SOUTHERN ASIA Myanmar Lao PDR Canada Colombia SOUTH-EAST ASIA Flows of heroin from/to countries or regions EAST AFRICA Opiate trafficking generated by production in Latin America Opiate trafficking generated by production in Myanmar/Lao People s Democratic Republic Opiate trafficking generated by production in Afghanistan SOUTH AMERICA SOUTHERN AFRICA OCEANIA Balkan route Northern route Southern route 1, 2, km Source: UNODC, responses to annual report questionnaire and individual drug seizure database. Notes: The trafficking routes represented on this map should be considered broadly indicative and based on data analyses rather than definitive route outlines. Such analyses are based on data related to official drug seizures along the trafficking route as well as official country reports and responses to annual report questionnaires. Routes may deviate to other countries that lie along the routes and there are numerous secondary flows that may not be reflected. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. The final boundary between the Sudan and South Sudan has not yet been determined. seized takes place in South-West Asia, followed by Europe. Accounting for 75 per cent of global opium seizures, 61 per cent of global morphine seizures and 17 per cent of global heroin seizures, the largest aggregated opiate seizures worldwide in 214 were reported by the Islamic Republic of Iran. The so-called Balkan route, which supplies Western and Central Europe with Afghan opiates, through Iran (Islamic Republic of) and Turkey via South-Eastern Europe, continues to be the most important conduit for heroin trafficking. However, the so-called southern route (through Pakistan or the Islamic Republic of Iran by sea to the Gulf region, Africa (particularly East Africa), South Asia and, to a lesser extent, South-East Asia, the Oceania region and North America), has grown in importance. Meanwhile, opiate trafficking on the so-called northern route, from Afghanistan to neighbouring States in Central Asia, the Russian Federation and other countries of the Commonwealth of Independent States, has started to undergo a resurgence after the decline in the period , while trafficking out of the Golden Triangle is on the increase, mainly due to rising levels of opium production in Myanmar after 26. Moreover, heroin trafficking in the Americas continues to increase, with heroin and morphine seizures rising from an average of 4 tons over the period to 7 tons per year over the period , in line with reported increases in opium production in Latin America over those periods. Cocaine Although global coca bush cultivation in 214 increased by 1 per cent from the previous year, the actual area under coca bush cultivation was the second smallest since the late 198s. Global cocaine manufacture was slightly higher than in the previous year but still per cent lower than the peak in 27, and thus basically back to the levels reported in the late 199s. At the same time, there are indications that the increase in global cocaine manufacture observed in 214 was not a one-off event and may have continued in 215. Cocaine trafficking via Africa may be regaining importance, and there are signs of increases in the trafficking of cocaine to Asia, particularly to East and South-East Asia and the Middle East, as cocaine seizures in Asia tripled from an average of.45 tons per year over the period to 1.5 tons per year over the period In Oceania, the cocaine market appears to be stabilizing, following rapid growth over the past decade. Despite these regional fluctuations, the annual prevalence of cocaine use remained largely stable at the global level over the period , fluctuating at between.3 and.4 per cent of the population aged However, as the population has grown, the number of cocaine users has increased, from some 14 million in 1998 to 18.8 million in 214. Meanwhile, it is likely that there has been a decline in per capita consumption of cocaine, prompted by a decline in the amount of cocaine available for con- WORLD DRUG REPORT 216

16 xiv Main trafficking flows of cocaine Canada WESTERN AND CENTRAL EUROPE United States of America Spain Australia SOUTH-EAST ASIA Mexico CARIBBEAN CENTRAL AMERICA Venezuela (Bol. Rep. of) Colombia Ecuador WEST AFRICA Qatar UAE Pakistan India China Hong Kong, China Malaysia Colombia Peru Brazil Panama Mexico Peru Brazil Argentina Peru Brazil Indonesia Australia Flows of cocaine from/to countries or regions Main trafficking Other trafficking Most frequently mentioned countries of provenance for individual drug seizure cases Bolivia (Plur. State of) Paraguay Chile Argentina South Africa Australia Canada United States of America Peru Chile Brazil Argentina 1, 2, km Source: UNODC, responses to annual report questionnaire and individual drug seizure database. Notes: The trafficking routes represented on this map should be considered broadly indicative and based on data analyses rather than definitive route outlines. Such analyses are based on data related to official drug seizures along the trafficking route as well as official country reports and responses to annual report questionnaires. Routes may deviate to other countries that lie along the routes and there are numerous secondary flows that may not be reflected. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. The final boundary between the Sudan and South Sudan has not yet been determined. sumption over the period , mainly linked to a drop in cocaine production in the Andean region. In parallel, the number of heavy cocaine users in North America has declined. This points to an overall shrinking of the cocaine market, although the number of (recreational rather than regular) cocaine users in several emerging markets continues to rise. Cannabis Despite major changes in some regions, global cannabis consumption has remained somewhat stable in recent years. In 214, some 3.8 per cent of the global population had used cannabis in the past year, a proportion that has remained stable since Given the global population growth, this has gone in parallel with an increase in the total number of cannabis users since The Americas, followed by Africa, remain the main production and consumption regions for cannabis herb, with about three quarters of all cannabis herb seizures worldwide taking place in the Americas in 214, the largest amounts in North America, while Africa accounted for 14 per cent of all cannabis herb seizures and Europe for 5 per cent. On the other hand, Europe, North Africa and the Near and Middle East remain the principal markets for cannabis resin, the majority of which continues to be produced in Morocco and Afghanistan, as reflected in information provided by Member States on the sources of cannabis resin seized. Accounting for 4 per cent of the total, the largest amounts of cannabis resin seized in 214 took place once again in Western and Central Europe. In the United States, although outcome measures such as the burden on the health and criminal justice systems need to continue to be monitored regularly, recent data from the states that have legalized marijuana for recreational use show an increase in cannabis use, as well as in public health and public safety indicators (cannabis-related emergency room visits, hospitalizations, traffic accidents and related deaths), while cannabis-related arrests, court cases and criminal justice system referrals into treatment have declined. Synthetics: amphetamine-type stimulants and new psychoactive substances After three years of relative stability, ATS seizures reached a new peak of more than 17 tons in 214. Since 29, global amphetamine seizures have fluctuated annually between about 2 and 46 tons, while ecstasy seizures more than doubled in 214, to 9 tons, compared with the annual averages of 4-5 tons since 29. For the past few years, methamphetamine seizures have accounted for the largest share of global ATS seizures annually, but, although methamphetamine is a feature of ATS markets worldwide, it is particularly dominant in East and South-East Asia and North America. Since 29, those subregions together have annually accounted for most global methamphetamine seizures. Compared with other subregions, North

17 EXECUTIVE SUMMARY xv Interregional trafficking flows of methamphetamine, East Asia North America Western, Central and South-Eastern Europe Eastern Europe Western Asia Central Asia East Asia Middle East Central America West Africa South-East Asia South America Oceania Significant flows within region Region with significant transit flows Region affected by methamphetamine flows Methamphetamine flows 1, 2, km Southern Africa Oceania Source: UNODC, responses to annual report questionnaire. Note: The origins of the flow arrows do not necessarily indicate the source/manufacture of methamphetamine. These arrows represent the flows as perceived by recipient countries. Flow arrows represent the direction of methamphetamine trafficking and are not an indication of the quantity trafficked. The boundaries shown on this map do not imply official endorsement or acceptance by the United Nations. Dashed lines represent undetermined boundaries. The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. The final boundary between the Sudan and South Sudan has not yet been determined. America has consistently reported the largest amount of methamphetamine seizures each year, whereas between 29 and 214, methamphetamine seizures reported in East and South-East Asia almost quadrupled. In Oceania, strong increases in methamphetamine seizures have been recorded since 212. There is a growing number of users of crystalline methamphetamine in the region, as well as increased frequency of use among certain user groups, an increase in methamphetamine purity and a decline in purity-adjusted prices, all of which could aggravate the negative impact on the health of individuals and on society in general. Large amounts of amphetamine tablets labelled with the brand name Captagon were reported to have been seized in the Middle East between March 214 and November 215. In 213 and 214, amphetamine seizures reported in the Middle East were mostly perceived to have originated in Lebanon and the Syrian Arab Republic. Over the same period, some countries reporting amphetamine seizures in the Middle East found that these were intended for trafficking onward to other destinations within the region. The NPS market continues to be characterized by the large number of new substances being reported. Although data collection for 215 is still in progress, 75 new substances have been reported to UNODC for the first time, compared with a total of only 66 new substances reported in 214. Between 212 and 214, most substances reported for the first time belonged to the group of synthetic cannabinoids, but the data reported for 215 so far show a different pattern: firstly, almost as many synthetic cathinones (2) were reported for the first time as were synthetic cannabinoids (21); secondly, a wide range of substances (21) not belonging to any of the major groups identified in previous years were reported for the first time, which included synthetic opioids (e.g., fentanyl derivatives) and sedatives (e.g., benzodiazepines). Significant quantities of NPS seized have been reported over the past few years. The global market for synthetic NPS continues to be dominated by synthetic cannabinoids (seizures of 32 tons), with North America (specifically the United States with 26.5 tons of seizures) accounting for the largest quantities seized worldwide in 214, out of the global total of 34 tons (excluding plant-based NPS and ketamine). However, global seizures of synthetic cathinones have been steadily increasing since they were first reported in 21, with seizures tripling to 1.3 tons in 214 from the previous year. UNODC monitoring of NPS since 28 has so far shown a rather dynamic supply situation with elements of persistence (a small number of substances emerge, spread and stay for several years) and change (a considerable number of substances appear for a short time or only locally). WORLD DRUG REPORT 216

18 xvi THE WORLD DRUG PROBLEM AND SUSTAINABLE DEVELOPMENT We welcome the 23 Agenda for Sustainable Development, and we note that efforts to achieve the Sustainable Development Goals and to effectively address the world drug problem are complementary and mutually reinforcing. Outcome document of the special session of the General Assembly on the world drug problem, entitled Our joint commitment to effectively addressing and countering the world drug problem The world drug problem is intertwined with all aspects of sustainable development. The analysis of the drug problem, and the response thereto, through the lens of the Sustainable Development Goals reveals the mechanisms of this interaction. All areas of sustainable development, as identified in the 17 Sustainable Development Goals, shape the nature and dynamic of the drug problem. At the same time, the impact of the drug problem, and the response thereto, on development can be observed at the individual, community and national levels. In analysing those linkages, the 17 Sustainable Development Goals have been divided into five broad areas: social development, economic development, environmental sustainability, peaceful, just and inclusive societies, and partnership. Social development Sustainable Development Goal 1. Reduce inequality within and among countries The failure to accept or understand that drug dependence is a health condition feeds the cycle of marginalization that often affects people with drug use disorders, making their recovery and social integration more challenging. Furthermore, stigmatizing attitudes towards people who use drugs, which may extend to staff in health-care services, can affect the delivery of effective treatment to those who most need it. Health REDUCED INEQUALITIES GOOD HEALTH AND WELL-BEING Sustainable Development Goal 3. Ensure healthy lives and promote well-being for all at all ages The Global Burden of Disease Study indicates that opioids, cocaine, amphetamines and cannabis together accounted for almost 12 million life years lost due to premature death or disability in 213, of which more than 8 Burden of drug use disorders The health impact of drug use increases with development (disability-adjusted life years per 1, population) Low Medium High Very high Global average Human development index By level of development Sources: Human development index from the United Nations Development Programme (UNDP); data on burden of disease (disability-adjusted life years) are from the Institute for Health Metrics and Evaluation, University of Washington, GBD Compare, 215. Available from million were linked to opioid use disorders. One of the risk factors for the negative health impact of drugs stems from their mode of administration. Injecting drug use, in particular, carries a much greater risk of overdose and infection, including the transmission of blood-borne viruses, such as HIV and hepatitis C, than does smoking, swallowing, snorting or inhaling drugs. Drug use may have repercussions on the health of society in general as PWID may become a group through which sexually transmitted diseases are passed on to other subgroups and the general population. Some studies also corroborate the hypothesis that the use of certain stimulants (whether injected or not) may also influence sexual behaviour itself, thereby increasing the likelihood of high-risk behaviour and sexual transmission a pattern that raises concern particularly in the case of specific at-risk groups such as men who have sex with men. Among its targets, Sustainable Development Goal 3 explicitly includes strengthening the prevention and treatment of substance abuse, including narcotic drug abuse. Drug policies based on scientific evidence can, through measures such as prevention and treatment, mitigate the negative health impact of drug use. But when policies are not appropriately tuned to the principles of the international drug control conventions, they can undermine the accessibility of controlled drugs for both medical and research purposes. Three quarters of the global population still have little or no access to medicines containing narcotic drugs and have inadequate access to treatment for moderate to severe pain. The importance of the accessibility of essential medicines, which typically include controlled drugs such as morphine, codeine, diazepam and phenobarbital, has

19 PARTNERSHIP EXECUTIVE SUMMARY xvii The world drug problem and sustainable development: a complex relationship SOCIAL DEVELOPMENT ECONOMIC DEVELOPMENT Drug use Drug supply SUSTAINABLE DEVELOPMENT SUSTAINABILITY ENVIRONMENTAL Response to the drug problem INCLUSIVE SOCIETY PEACEFUL, JUST AND been recognized in target 3.b of the Sustainable Development Goals. Women, girls and youth Drug use undermines the aspect of sustainable development related to gender equality and the empowerment of women and girls. There are marked differences between male and female drug users in terms of preferred drugs and drug-related vulnerabilities. Coupled with the fact that users of several drug types are predominantly male, this leads to a danger that the entire continuum of care may fail to cater adequately for the needs of female drug users, who also have a lack of access to such services. GENDER EQUALITY Sustainable Development Goal 5. Achieve gender equality and empower all women and girls Women affected by drug dependence and HIV are more vulnerable and more stigmatized than men. They suffer from co-occurring mental health disorders to a greater extent than men, and they are more likely to have been victims of violence and abuse. Women often also bear a heavy burden of violence and deprivation associated with the drug dependence of family members, hindering the achievement of the sustainable development target of eliminating all forms of violence against all women and girls. Female offenders and prisoners, especially those with drug use disorders, face particular hardship as, in many instances, criminal justice systems are not yet equipped for the special needs of women. Drug use often affects people during their most productive years. When youth become trapped in a cycle of drug use, and even in the drug trade itself, as opposed to being engaged in legitimate employment and educational opportunities, distinct barriers are effectively raised to the development of individuals and communities. Economic development NO POVERTY Sustainable Development Goal 1. End poverty in all its forms everywhere The toll taken by the drug problem may vary in size and shape across countries, both developed and developing, but in one way or another it affects all. Vulnerability to drugs, be it in terms of cultivation, production, trafficking or use, exists in countries at all levels of development. The relationship between economic development and drugs is particularly evident in the case of the illicit cultivation of drug crops. In rural areas, socioeconomic elements such as poverty and a lack of sustainable livelihoods are important risk factors leading farmers to engage in illicit cultivation. They are also manifestations of poor levels of development which, alongside other development issues linked to security and governance, are enabling elements of large-scale illicit cultivation. Higher socioeconomic groups have a greater propensity to initiate drug use than lower socioeconomic groups, but it is the lower socioeconomic groups that pay the higher price as they are more likely to become drug dependent Poverty also has strong links with drug use, albeit in a complex and mutually reinforcing manner. Indeed, the brunt of the drug use problem is borne by people who are poor in relation to the societies in which they live, as can be seen in stark terms in the wealthier countries. More broadly, there is a strong association between social and WORLD DRUG REPORT 216

20 xviii The impact of income on drug use depends on the type of drug Prevalence (percentage) Amphetamines* Income level Opiates Low Lower Upper High middle middle Income level Prevalence (percentage) Cocaine "Ecstasy" Income level Low Lower Lower middle Upper Upper middle High High Income level Global average By income level Source: World Bank (for income levels) and UNODC estimates based on responses to the annual report questionnaire and other official sources (for drug use data). * Including prescription stimulants. economic disadvantage and drug use disorders. This pattern can also be seen when looking at different reflections of marginalization and social exclusion, such as unemployment and low levels of education. Beyond development, a multitude of factors, including geographic location, play a role in shaping the drug problem in a given country. Proximity to a drug-producing area or a major drug trafficking route can, for example, explain the above-average rates of opiate use in the Near and Middle East and South-West Asia, and use of cocaine, including crack cocaine, in South America and West Africa. A breakdown of national data on people who use drugs, based on income level, shows, however, that highincome countries tend to have a higher prevalence of past-year drug use across the drug categories. Drugs that can command a relatively high price, and ultimately higher profits for traffickers, find an easier foothold in countries with relatively higher levels of per capita income. In the case of substances such as cocaine and heroin, the level of economic development contributes to the formation of consumer markets that are large in terms of both number of users and total revenue. Different levels of socioeconomic well-being within individual countries also have an effect on the type of drugs used. For example, in the United States, the association between drug use and unemployment is much stronger in the case of crack cocaine than other types of cocaine. Drug markets tend to be influenced by local idiosyncrasies in both developed and developing countries, but sizeable markets for certain substances, notably cocaine and synthetic substances, have taken hold in developed countries before subsequently expanding to developing countries. Prime examples are the emergence of ecstasy and other hallucinogens in North America and Europe, as well as the ongoing proliferation of the consumption of NPS in Europe, Japan and North America. The relationship between development and the drug problem thus needs to be viewed in dynamic terms. Environmental sustainability LIFE ON LAND Sustainable Development Goal target Take urgent and significant action to reduce the degradation of natural habitats, halt the loss of biodiversity and, by 22, protect and prevent the extinction of threatened species Illicit crop cultivation often occurs in forested areas and contributes to deforestation when it results in the clearing of woodland. Moreover, illicit crop cultivation frequently takes place in biodiversity hotspots hosting a large number of species with a limited habitat, some of which are protected areas. It tends to occur close to the agricultural frontier, which demarcates the border between pristine forest and developed areas, and can result in the clearing of forests. Although empirical evidence and rigorous analysis do not support the claim that illicit cultivation is the